Predicting drug resistance in adult patients with generalized epilepsy: A case–control study

ObjectivesUsing an adult cohort of patients with generalized epilepsy, we aimed to identify risk factors for development of drug-resistant epilepsy (DRE), which if identifiable would allow patients to receive earlier treatment and more specifically individualized treatment plans.MethodsFor the case–control study, 118 patients with generalized epilepsy (GE) between the ages of 18 and 75 were included after selection from a database of 800 patients referred from throughout the Saskatchewan Epilepsy Program. Definitions were used in accordance with ILAE criteria. The odds ratio and its confidence interval were calculated. We performed a logistic regression analysis.ResultsForty-four (37%) patients fulfilled the definition of DRE (cases), and seizures in 74 (63%) patients were not intractable (controls). Patients with DRE were significantly younger than the controls at the onset of epilepsy (6.6 vs. 18.8 years, p = < 0.001). Significant variables on univariate analysis were the following: epilepsy diagnosed prior to 12 years (OR: 12.1, CI: 4.8–29.9, p < 0.001), previous history of status epilepticus (OR: 15.1, CI: 3.2–70.9, p < 0.001), developmental delay (OR: 12.6, CI: 4.9–32, p < 0.001), and cryptogenic epilepsy (OR: 10.5, CI: 3.9–27.8, p < 0.001). Our study showed some protective factors for DRE such as a good response to first AED, idiopathic etiology, and history of febrile seizures. In the logistic regression analysis, two variables remained statistically significant: developmental delay and more than one seizure type.ConclusionOur study has identified a set of variables that predict DRE in patients with generalized epilepsy. Risk factors identified in our study are similar to those previously identified in pediatric studies, however, our study is specifically tailored to adult patients with generalized epilepsy.     

Decision-making in patients with temporal lobe epilepsy: Delay gratification ability is not impaired in patients with hippocampal sclerosis

BackgroundDecision-making abilities have rarely been examined in patients with temporal lobe epilepsy related to hippocampal sclerosis (TLE-HS). We aimed to investigate the ability to delay gratification, a decision-making subdomain, in patients with intractable TLE-HS and to verify the association of delay gratification performance and cool executive function tests.MethodsWe evaluated 27 patients with TLE-HS (mean age: 35.46 [± 13.31] years; 7 males) and their cognitive performance was compared with that of 27 age- and gender-matched healthy controls (mean age: 35.33 [± 12.05] years; 7 males), without epilepsy and psychiatric disorders. Patients were assessed using the delay discounting task (DDT) and tests of attention, shifting, inhibitory control, and concept formation. Results were correlated with clinical epilepsy variables such as age of onset, epilepsy duration, AED use, history of status epilepticus, febrile seizures, and the presence of generalized seizures. Statistical analysis was performed using one-way ANCOVA with years of education as a confounding factor.ResultsPatients and controls demonstrated similar performance on DDT, showing similar discount rate (p = 0.935) and probability rate (p = 0.585). Delay gratification was not related to cool executive function tests (Digit Span, Stroop Color Test, Trail Making Test, Wisconsin Card Sorting Test, and Connors' CPT). History of status epilepticus, presence of generalized seizures and higher seizure frequency, age at onset, and epilepsy duration had a significant impact on DDT.ConclusionPatients with intractable TLE-HS showed unimpaired delay gratification abilities, being able to accept a higher delay and a lower amount of chance for receiving a higher reward in the future. Clinical variables related to the epilepsy severity impacted the performance on delay gratification. Impairment on cool aspects of executive function was unrelated to this decision-making domain.     

The impact of stereotactic laser ablation at a typical epilepsy center

PurposeStereotactic laser ablation (SLA) is a novel form of epilepsy surgery for patients with drug-resistant focal epilepsy. We evaluated one hundred consecutive surgeries performed for patients with epilepsy to address the impact of SLA on our therapeutic approach, as well as patient outcomes.MethodsA retrospective, single center analysis of the last one hundred neurosurgeries for epilepsy was performed from 2013 to 2015. Demographics, surgical procedures, and postoperative measures were assessed up to 5 years to compare the effect of SLA on outcome. Confidence intervals (CI) and comparative tests of proportions compared outcomes for SLA and resective surgery. Procedural categorical comparison used Chi-square and Kaplan–Meier curves. Student t-test was utilized for single variables such as age at procedure and seizure onset.ResultsOne hundred surgeries for epilepsy yielded thirty-three SLAs and twenty-one resections with a mean of 21.7-month and 21.3-month follow-up, respectively. The temporal lobe was the most common target for SLA (92.6%) and resection (75%). A discrete lesion was present on brain magnetic resonance imaging (MRI) in 27/32 (84.4%) of SLA patients compared with 7/20 (35%) of resection patients with a normal MRI. Overall, 55–60% of patients became seizure-free (SF). Four of five patients with initial failure to SLA became SF with subsequent resection surgery. Complications were more frequent with resection although SF outcomes did not differ (Chi square; p = 0.79). Stereotactic laser ablation patients were older than those with resections (47.0 years vs. 35.4 years, p = 0.001). The mean length of hospitalization prior to discharge was shorter for SLA (1.18 days) compared with open resection (3.43 days; SD: 3.16 days) (p = 0.0002).ConclusionWe now use SLA as a first line therapy at our center in patients with lesional temporal lobe epilepsy (TLE) before resection. Seizure-free outcome with SLA and resection was similar but with a shorter length of stay. Long-term follow-up is recommended to determine sustained SF status from SLA.     

Cognition in patients with benign epilepsy with centrotemporal spikes: A study with long-term VEEG and RS-fMRI

ObjectiveThe purpose of this study was to investigate the relationship between alterations of functional brain network and cognition in patients with benign epilepsy with centrotemporal spikes (BECTS) as a function of spike-wave index (SWI) during slow wave sleep.MethodsResting-state functional magnetic resonance imaging (RS-fMRI) data and Intelligence Quotient (IQ) were collected from two groups of patients with BECTS, including a SWI < 50% group (5 cases) and a SWI ≥ 50% group (7 cases). The SWI was calculated from the long-term video-electroencephalogram monitoring (one sleep cycle was included at least). The RS-fMRI data were analyzed by regional homogeneity (ReHo) method.ResultsThere were three main findings. Firstly, Full Intelligence Quotient (FIQ), Verbal Intelligence Quotient (VIQ), and Performance Intelligence Quotient (PIQ) of the SWI ≥ 50% group were significantly lower than SWI < 50% group (p < 0.05). Secondly, there was a negative correlation between the FIQ, VIQ, PIQ, and SWI (p < 0.05), and the FIQ, VIQ, and PIQ were not dependent on age, age of onset, disease course, years of education, and total number of seizures (p > 0.05). Finally, compared with the SWI < 50% group, the SWI ≥ 50% group showed increased ReHo in the bilateral precentral gyrus, bilateral premotor area, bilateral subcortical structure, right temporal lobe, and bilateral insular lobe, while they showed decreased ReHo in the posterior cingulate cortex and posterior of right inferior temporal lobe.ConclusionsThe alterations of functional brain network caused by the frequent discharges during slow wave sleep could affect cognition in patients with BECTS.     

Drug-resistant focal epilepsy in women of childbearing age: Reproduction and the effect of epilepsy surgery

ObjectiveWomen with epilepsy (WWE) have lower birth rates than expected. The reasons for this are multifactorial and involve a complex interaction between reproductive endocrine and psychosocial factors. The effect of epilepsy surgery on reproduction in women with drug-resistant focal epilepsy has not previously been studied.MethodsAdult women of childbearing age (18–45 years old) with drug-resistant focal epilepsy who had undergone a focal cortical resection between 1997 and 2008 at the Mayo Clinic in Rochester, MN were included in the study. Patients who had a history of hysterectomy or tubal ligation or who were menopausal at the time of surgery were excluded. Data on prior pregnancies and births, epilepsy history, surgical treatment, hormonal dysfunction, and socioeconomic status were obtained using a retrospective chart review. Associations between various clinical and demographic variables with changes in pregnancies and births from pre- to postsurgery were assessed using Chi-square or Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. All tests were 2-sided, and p-values less than 0.05 were considered statistically significant. All analyses were performed using SAS software version 9.2 (SAS INC, Cary NC).ResultsOne hundred and thirteen women (average age: 30.5 years) were included in the study. Average length of follow-up was 5.7 years (SD-3.90). Sixty-four patients (57.5%) were nulliparous at the time of surgery. Sixty-one patients (54%) had never been married. Average number of pregnancies per patient prior to surgery was 0.93, and average number of births prior to surgery was 0.73. After surgery, a total of 17 women had a total of 35 pregnancies and 25 births. The average number of pregnancies and births after surgery was 1.27 and 0.96, respectively. Infertility was reported in one patient postoperatively. Patients who were younger at the time of surgery experienced a greater change in the number of pregnancies and births after surgery (p = 0.0036 and 0.0060, respectively). Patients who received fewer antiepileptic drug medication trials by the time of surgery also had a greater change in the number of births after surgery (p = 0.0362). Seizure onset localization and lateralization, presurgical seizure frequency, age at seizure onset, duration of epilepsy, and postoperative seizure outcome were not statistically significant factors.ConclusionThe present retrospective observational study provides additional evidence for the importance of early surgical treatment in women with drug-resistant focal epilepsy. Patients who had received fewer medications prior to surgery were more likely to experience an increase in births following surgery. The significance of these findings requires further investigation but may support a role for earlier surgical intervention in the management of drug-resistant focal epilepsy.     

Predictive factors of postoperative outcome in the elderly after resective epilepsy surgery

ObjectiveTo evaluate the efficiency of resective epilepsy surgery (RES) in patients over 50 years and determine prognostic factors.ResultsOver the 147 patients over 50 years (54.9 ± 3.8 years [50–69]) coming from 8 specialized French centres for epilepsy surgery, 72.1%, patients were seizure-free and 91.2% had a good outcome 12 months after RES. Seizure freedom was not associated with the age at surgery or duration of epilepsy. In multivariate analysis, seizure freedom was associated with MRI and neuropathological hippocampal sclerosis (HS) (P = 0.009 and P = 0.028 respectively), PET hypometabolism (P = 0.013), temporal epilepsy (P = 0.01). On the contrary, the need for intracranial exploration was associated with a poorer prognosis (P = 0.001). Postoperative number of antiepileptic drugs was significantly lower in the seizure-free group (P = 0.001). Neurological adverse event rate after surgery was 21.1% and 11.7% of patients had neuropsychological adverse effects overall transient.ConclusionsRES is effective procedure in the elderly. Even safe it remains at higher risk of complication and population should be carefully selected. Nevertheless, age should not be considered as a limiting factor, especially when good prognostic factors are identified.     

Health-related quality of life in adolescents with epilepsy in Montenegro

ObjectiveThe objective of this study was to establish potential risk factors for poor health-related quality of life among adolescents with epilepsy in Montenegro.Material and methodsA sample of 104 adolescents with epilepsy (age: 11–19 years) at a tertiary referral center in Podgorica, Montenegro, completed the validated Serbian version of the QOLIE-AD-48 questionnaire. They were divided into two groups: a group with active epilepsy (60 adolescents) and a group with inactive epilepsy (44 adolescents). Demographic and clinical data were collected.ResultsAdolescents with active epilepsy had low quality of life and felt the negative impact of the disease. They also had more cognitive impairments, felt more stigmatized, and had considerably more distorted perception of their health than adolescents with inactive epilepsy (p < 0.05). Females reported better social support than males (p < 0.05). Older males had lower grades at school (p < 0.05) than the younger ones. As expected, adolescents with the highest number of seizures in the past two years had the lowest quality of life (p < 0.05).ConclusionIn our study, the quality of life in adolescents with epilepsy was determined by severity of the disease, age, and gender.     

Outcome of psychogenic nonepileptic seizures (PNES) in children: A 2-year follow-up study

ObjectiveThe objective of this study was to determine the outcome of psychogenic nonepileptic seizures (PNES) in children seen at a level 4 epilepsy center.MethodsWe retrospectively analyzed patients under the age of 18 years who were diagnosed with PNES based on evaluation in the epilepsy monitoring unit and had a follow-up of at least 2 years postdiagnosis. Remission of events was noted at 6 months, 12 months, and 24 months of follow-up, and patient and disease variables affecting outcome were studied.ResultsNinety patients met inclusion criteria (58 females; mean age: 14.03 ± 3.3 years). Thirty-two out of ninety (36%) patients had early (within 6 months) and sustained remission (until 2 years of follow-up) of their events (“favorable outcome”), while 30/90 patients (33%) never achieved remission during the study period (“unfavorable outcome”). The factors that were associated with “unfavorable outcome” included the presence of comorbid epilepsy [12/30 (40%) vs 0/32, p < 0.0001] and prolonged duration of symptoms before establishment of the diagnosis (median 365 days vs 60 days, p < 0.0001). Patient's age, gender, frequency of events, the presence of major psychosocial stressors, and comorbid psychiatric conditions had no significant impact on the disease outcome.ConclusionsAbout a third of children with PNES achieve early and sustained remission of symptoms, while another third continue to manifest seizure-like events until at least two years after the diagnosis. The presence of comorbid epilepsy and prolonged duration of PNES are associated with a poor two-year outcome. Early suspicion and diagnosis of PNES, especially in patients with epilepsy, is essential.     

Morbidity and mortality of childhood- and adolescent-onset epilepsy: A controlled national study

PurposeEpilepsy is associated with significant morbidities and mortality. We aimed to evaluate the 30-year morbidities and mortality in a national group of patients after a first diagnosis of epilepsy.MethodsFrom the Danish National Patient Registry (NPR), in total, 3123 patients with epilepsy aged 0–5 years and 5018 patients aged 6–20 years diagnosed in 1998–2002 were identified and compared with, respectively, 6246 and 10,036 persons matched for age, gender, and place of living with randomly chosen citizens from the Danish Civil Registration System Statistics. In the NPR, all morbidities in the following 30 years were grouped into major WHO disease classes.Key findingsPatients with epilepsy had significantly higher rates of comorbidities including almost all health-related comorbidities compared with controls. Mortality rates were elevated: the hazard ratio (5%; 95% CI) was 14.46 (11.8; 17.7, p < 0.001) and 5.58 (4.9; 6.4, P < 0.001) for patients aged 0–5 years and 6–20 years at first diagnosis of epilepsy, respectively.SignificanceEpilepsy is associated with significant comorbidities and mortality including all health care domains, especially among persons who were young at the onset of epilepsy.     

Distinct domains of impulsivity are impaired in juvenile myoclonic epilepsy but not in temporal lobe epilepsy

ObjectiveThe Barratt Impulsiveness Scale (BIS-11) is the most widely used questionnaire to study impulsivity in persons with psychiatric disorders, but it has rarely been applied to persons with epilepsy. The present study aimed to evaluate the usefulness of BIS-11 as a tool to explore impulsivity in two distinct epilepsy syndromes.MethodThe BIS-11 was applied to 20 patients with juvenile myoclonic epilepsy (JME) (32.5 ± 8.95 years old), 20 patients with temporal lobe epilepsy (TLE) (37.7 ± 13.25 years old), and 26 healthy controls (31.86 ± 11.25 years old). The scores in motor, attentional, and lack of planning impulsivity were compared between groups.ResultsPatients with JME showed higher scores than patients with TLE and controls in all domains: motor (JME vs TLE: 28.60 vs 13.25 (mean score), p < 0.001 and JME vs controls: 28.60 vs 14.12, p < 0.001), attentional (JME vs TLE: 21.55 vs 13.45, p < 0.001 and JME vs controls: 21.55 vs 14.88, p < 0.001) and nonplanning (JME vs TLE: 28.05 vs 13.10, p < 0.001 and JME vs controls: 28.05 vs 16.15, p < 0.001).ConclusionHigher BIS-11 scores in all domains of impulsivity [i.e., motor, attentional, and lack of planning] corroborated previous findings described in patients with JME. On the other hand, BIS-11 could not demonstrate problem solving and inhibitory control deficits related to impulsive behavior, which were described in patients with TLE. Other behavioral measures may be more sensitive to some aspects of impulsivity in TLE. Our results reinforce the concept that distinct epileptic syndromes require different neuropsychological approaches, especially considering a complex construct such as impulsivity.     

Academic achievement one year after resective epilepsy surgery in children

PurposeFew studies have examined the academic functioning of children following pediatric epilepsy surgery. Although intellectual functioning has been more thoroughly investigated, children with epilepsy may experience additional difficulties with academic skills. This study examined the academic outcomes of a cohort of children who underwent pediatric epilepsy surgery on an average 1.2 (standard deviation [SD]: 0.3) years prior.MethodsParticipants were 136 children (mean age: 14.3 years, [SD]: 3.7 years) who had undergone resective epilepsy surgery. Academic functioning was assessed presurgery and postsurgery using standardized tests of reading, reading comprehension, arithmetic, and spelling.ResultsAt baseline, 65% of the children displayed low achievement (1 SD below test mean), and 28% had underachievement (1 SD below baseline IQ) in at least one academic domain. Examining change over time revealed that reading, numeral operations, and spelling significantly declined among all patients; seizure freedom at follow-up (attained in 64% of the patients) did not influence this relationship. Reading comprehension and IQ remained unchanged. Similar findings were found when examining patients with a baseline IQ of ≥ 70 and when controlling for IQ. Regression analyses revealed that after controlling for IQ, demographic and seizure-related variables were not significantly associated with academic achievement at follow-up.ConclusionsResults show baseline academic difficulties and deteriorations following surgery that go beyond IQ. Further investigations are required to determine whether the observed deteriorations result from the development of the child, the course of the disorder, or the epilepsy surgery itself. Long-term studies are warranted to identify the progression of academic achievement and whether the observed deteriorations represent a temporal disruption in function.     

Cardiac autonomic dysfunction in drug naïve hot water epilepsy

PurposeThis study aimed to characterize the role of autonomic nervous system dysfunction in hot water epilepsy (HWE). Heart rate variability (HRV) has been established as a good index of cardio-autonomic regulation.MethodologyForty-five patients with HWE (age: 24.6 ± 10.1 years; M:F = 37:8) and 45 age and gender matched controls (age: 24.17 ± 10.37 years; M:F = 37:8) were studied. Five minutes resting lead II electrocardiogram (ECG) was obtained (AD instruments) under standard conditions and analyzed for time and frequency domain HRV parameters using LabChart software.ResultPatients with hot water epilepsy showed significant increase in LF nu (Low frequency normalized unit) and LF/HF denoting an interictal increase in sympathetic activity. In addition, reductions were noted in parasympathetic function [RMSSD (root mean square successive difference of RR intervals), HF (High frequency) nu and LF/HF].ConclusionThis study has demonstrated an impaired sympatho-vagal balance characterized by increased sympathetic activity and reduced parasympathetic activity in patients with HWE. The present study supports the notion that the hypothalamus is involved in both, the pathogenesis of HWE and autonomic regulation.     

Atypical handedness in mesial temporal lobe epilepsy

ObjectiveThe main aim of our study was to investigate the handedness of patients with mesial temporal lobe epilepsy (MTLE). We also sought to identify clinical variables that correlated with left-handedness in this population.MethodsHandedness (laterality quotient) was assessed in 73 consecutive patients with MTLE associated with unilateral hippocampal sclerosis (HS) using the Edinburgh Handedness Inventory. Associations between right- and left-handedness and clinical variables were investigated.ResultsWe found that 54 (74.0%) patients were right-handed, and 19 (26%) patients were left-handed. There were 15 (36.6%) left-handed patients with left-sided seizure onset compared to 4 (12.5%) left-handed patients with right-sided seizure onset (p = 0.030). Among patients with left-sided MTLE, age at epilepsy onset was significantly correlated with handedness (8 years of age [median; min-max 0.5–17] in left-handers versus 15 years of age [median; min-max 3–30] in right-handers (p < 0.001).ConclusionsLeft-sided MTLE is associated with atypical handedness, especially when seizure onset occurs during an active period of brain development, suggesting a bi-hemispheric neuroplastic process for establishing motor dominance in patients with early-onset left-sided MTLE.     

Welfare cost of childhood- and adolescent-onset epilepsy: A controlled national study

ObjectivesEpilepsy is associated with a significant burden to patients and society. We calculated the factual excess in direct and indirect costs associated with childhood- and adolescent-onset epilepsy.MethodsUsing records from the Danish National Patient Registry (1998–2002), we identified 3123 and 5018 patients with epilepsy aged 0–5 years and 6–20 years at the time of diagnosis, respectively. The two age groups of patients with epilepsy were matched to 6246 and 10,036 control persons without epilepsy, respectively, by gender, age, and geography. The controls were randomly chosen from the Danish Civil Registration System. Welfare costs included outpatient services, inpatient admissions, and emergency room visits based on the Danish National Patient Registry and information from the primary health-care sector based on data from the Danish Ministry of Health. This allowed the total health-care cost of epilepsy to be estimated. The use and costs of drugs were based on data from the Danish Medicines Agency. The frequencies of visits to outpatient clinics and hospitalizations and costs from primary sectors were based on data obtained from the National Patient Registry.ResultsChildren with epilepsy had higher welfare costs than controls. The highest cost was found one year after diagnosis, with higher costs up to 10 years after diagnosis compared with controls. Children aged 0–5 years incurred greater health-care costs than those aged 6–20 years.ConclusionEpilepsy has major socioeconomic consequences for the individual person with epilepsy and for society.     

Stroke after adult-onset epilepsy: A population-based retrospective cohort study

BackgroundEarlier studies indicate a higher risk of subsequent stroke in PWE aged ≥60. However, little is known of the incidence of subsequent stroke in people with epilepsy (PWE) aged 35 through 60. We determined the risk factors that increase the incidence of stroke following adult-onset epilepsy in a large statewide population over a 10-year period.MethodsSouth Carolina hospital discharge and emergency department (ED) data from 2000 to 2011 were used. The study was limited to persons aged ≥ 35 years without prior stroke. Cases included patients diagnosed with epilepsy who were hospitalized or visited the ED. Controls were people with an isolated fracture of the lower extremity without any history of epilepsy or seizure disorders, presumed to approximate the health status of the general population. Epilepsy, fracture, stroke, and comorbid conditions were ascertained by diagnostic codes from health-care encounters. Only persons having stroke occurring ≥ 6 months after the onset of epilepsy or after the first clinical encounter for controls were included. Cox proportional hazards modeling was performed to determine the risk of stroke.ResultsThere were 21,035 cases with epilepsy and 16,638 controls who met the inclusion criteria. Stroke incidence was 2.5 times higher following adult-onset epilepsy (6.3%) compared with controls (2.5%). After adjusting for comorbidities and other factors, cases with epilepsy showed a 60% higher risk of stroke (HR = 1.6; 95% CI: 1.42–1.80) compared with controls. Nearly half of the strokes in cases with epilepsy occurred in those with first diagnosis between ages 35 and 55. Somatic comorbidities associated with increased risk of stroke were more prevalent in cases with epilepsy than controls yet similar in both groups with stroke. Risk of stroke increased with increasing age in both groups. However, the risk of stroke in cases with epilepsy increased faster and was similar to that in controls who were ≥ 10 years older.ConclusionAdult-onset epilepsy at age 35 and older warrants consideration for occult cerebrovascular disease as an etiology of the epilepsy, which may also increase the risk of subsequent stroke. Somatic comorbidities frequently associated with epilepsy include comorbid conditions that share the same underlying pathology with stroke (i.e., hypertension, hyperlipidemia, myocardial infarction, diabetes, and arteriosclerosis). This increased risk of stroke in patients with adult-onset epilepsy should dictate the evaluation and management of stroke risk factors to prevent stroke.     

Specific adverse effects of antiepileptic drugs — A true-to-life monotherapy study

BackgroundIn patients taking antiepileptic drugs (AEDs) for epilepsy, adverse effects (AEs) often lead to unfavorable quality of life, impaired adherence, and, eventually, discontinuation of pharmacological treatment. In a true-to-life sample of subjects from our academic epilepsy outpatient clinic, we aimed to identify predictors for overall high AE burden and for specific AEs focusing on patients on monotherapy.MethodsAll patients ≥ 16 years of age with epilepsy for ≥ 12 months were routinely asked to complete the Liverpool Adverse Event Profile (LAEP) just before their appointment. Demographic, epilepsy, and treatment variables were derived from our comprehensive outpatient database.ResultsOut of 841 patients, 438 (61% female, mean age: 44.7 ± 17.1 years) on monotherapy were included in this study. Levetiracetam (n = 151), lamotrigine (n = 167), valproic acid (n = 73), or controlled-release carbamazepine (n = 47) were the most commonly used antiepileptic drugs (AEDs). Independent predictors for general high AE burden (LAEP score ≥ 45) were duration of epilepsy, lack of 12-month seizure freedom, and partial epilepsy, but none of the four individual AEDs. The most frequent LAEP-defined specific AEs were sleepiness, difficulty concentrating, tiredness, and memory problems. The three most frequent independent predictors for each of the 19 AEs were lack of 12-month seizure freedom (13/19 AEs), individual AED (7/19 AEs), and partial epilepsy (6/19 AEs). Levetiracetam was independently associated with anger/aggression, nervousness/agitation, upset stomach, depression, and sleep disturbance; lamotrigine with nervousness/agitation, upset stomach, and difficulty concentrating; and valproic acid with upset stomach and shaky hands.ConclusionIndividual AEDs independently predicted some specific AEs, but not overall high AE burden. Our findings may help to characterize patients with epilepsy who are at high risk for specific AEs. Dose reduction or change to another AED may reduce LAEP score and potential nonadherence.     

Long-term outcome and predictors of resective surgery prognosis in patients with refractory extratemporal epilepsy

PurposeWe analyzed the long-term postoperative outcome and possible predictive factors of the outcome in surgically treated patients with refractory extratemporal epilepsy.MethodsWe retrospectively analyzed 73 patients who had undergone resective surgery at the Epilepsy Center Brno between 1995 and 2010 and who had reached at least 1 year outcome after the surgery. The average age at surgery was 28.3 ± 11.4 years. Magnetic resonance imaging (MRI) did not reveal any lesion in 24 patients (32.9%). Surgical outcome was assessed annually using Engel's modified classification until 5 years after surgery and at the latest follow-up visit.ResultsFollowing the surgery, Engel Class I outcome was found in 52.1% of patients after 1 year, in 55.0% after 5 years, and in 50.7% at the last follow-up visit (average 6.15 ± 3.84 years). Of the patients who reached the 5-year follow-up visit (average of the last follow-up 9.23 years), 37.5% were classified as Engel IA at each follow-up visit. Tumorous etiology and lesions seen in preoperative MRI were associated with significantly better outcome (p = 0.035; p < 0.01). Postoperatively, 9.6% patients had permanent neurological deficits.ConclusionSurgical treatment of refractory extratemporal epilepsy is an effective procedure. The presence of a visible MRI-detected lesion and tumorous etiology is associated with significantly better outcome than the absence of MRI-detected lesion or other etiology.     

Auditory verbal memory and psychosocial symptoms are related in children with idiopathic epilepsy

ObjectiveIdiopathic epilepsies are considered to have relatively good prognoses and normal or near normal developmental outcomes. Nevertheless, accumulating studies demonstrate memory and psychosocial deficits in this population, and the prevalence, severity and relationships between these domains are still not well defined. We aimed to assess memory, psychosocial function, and the relationships between these two domains among children with idiopathic epilepsy syndromes using an extended neuropsychological battery and psychosocial questionnaires.MethodsCognitive abilities, neuropsychological performance, and socioemotional behavior of 33 early adolescent children, diagnosed with idiopathic epilepsy, ages 9–14 years, were assessed and compared with 27 age- and education-matched healthy controls.ResultsCompared to controls, patients with stabilized idiopathic epilepsy exhibited higher risks for short-term memory deficits (auditory verbal and visual) (p < 0.0001), working memory deficits (p < 0.003), auditory verbal long-term memory deficits (p < 0.0021), and more frequent psychosocial symptoms (p < 0.0001). The severity of auditory verbal memory deficits was related to severity of psychosocial symptoms among the children with epilepsy but not in the healthy controls.SignificanceResults suggest that deficient auditory verbal memory may be compromising psychosocial functioning in children with idiopathic epilepsy, possibly underscoring that cognitive variables, such as auditory verbal memory, should be assessed and treated in this population to prevent secondary symptoms.     

Impact of a family history of epilepsy on the diagnosis of epilepsy in southern Saudi Arabia

PurposeEpilepsy can develop at any age for reasons that remain poorly understood. The aim of this study was to determine the impact of a family history of epilepsy (FHE) on the incidence and recurrence of seizures.MethodsThis retrospective study was conducted in Aseer central hospital, Abha, Saudi Arabia between January and June 2012. The medical records of 420 patients were analyzed to test the impact of FHE on the risk factors, etiology and diagnosis of epilepsy determined by magnetic resonance imaging (MRI) and electroencephalography (EEG).Results420 patients were studied. Idiopathic epilepsy was seen in 140 patients (33%), symptomatic in 152 (36%), and cryptogenic in 128 patients (30%). FHE was seen in 113 patients (27%), which was associated with younger at the disease onset (15 years vs 20 years, p < 0.05). Idiopathic epilepsy was seen more in patients with FHE (43% vs 30%, p value <0.05), and generalized seizures (primary or secondary) were also seen more in patients with FHE (51% vs 36%, p value <0.05). Abnormal EEG was also seen more in patients with FHE (79% vs 66%, p < 0.05). Multivariate regression analysis showed that temporal epileptic discharges were the best predictor for the presence of FHE (p < 0.05, OR = 3.1, 95% CI 1.7–5.8), more than idiopathic epilepsy or younger age at epilepsy onset.ConclusionsFHE has a significant impact on epilepsy, its classifications, and the EEG findings, and may underlie the presence of a genetic etiology, which could be related to a high incidence of consanguinity seen in our population. Temporal epileptic discharges were the best predictor for FHE, which may suggest the presence of familial TLE.     

Paroxysmal nonepileptic events in pediatric patients

ObjectivesParoxysmal nonepileptic events (PNEs) are frequently encountered phenomena in children. Although frequencies and types of PNEs have been extensively studied in adult populations, the data available for children and adolescents are limited, especially in patients without underlying neurologic disorders. In this study, we evaluated and compared the characteristics of PNEs between age groups and according to the presence of neurologic deficits to improve early detection and diagnosis of PNEs.MethodsWe retrospectively reviewed 887 pediatric patients who were admitted to the epilepsy monitoring unit at the Samsung Medical Center between December 2001 and July 2014. One hundred and forty-one patients (15.9%) were diagnosed as having PNEs on the basis of their clinical history and long-term video-electroencephalography (EEG) monitoring (VEM).ResultsChildren with PNEs were divided into three groups by age: 1) the infant, toddler, and preschool group (< 6 years, N = 50, 35.5%); 2) the school-age group (6–< 12 years, N = 30, 21.3%); and 3) the adolescent group (12–< 18 years, N = 61, 43.3%). Physiologic disorders, such as normal infant behavior, sleep movement, and staring, were more common in patients younger than 6 years of age, whereas psychogenic nonepileptic seizures were predominant in patients older than 6 years. Vasogenic syncope was also frequently observed in the adolescent group and was confirmed by the head-up tilt test. There was no significant difference in specific PNE types between the groups of patients with or without neurologic deficits.ConclusionsPhysiologic symptoms were predominant in the younger age group, whereas psychogenic nonepileptic seizures were observed in older age groups more often. Clinical pattern recognition by age plays an important role in clinical practice, because pediatric patients present various types of PNEs with age-specific patterns. Considering various and inconsistent presentations and the importance of correct diagnosis, long-term VEM can be helpful in diagnosing normal infant behavior and psychogenic nonepileptic seizures.